A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

Hold the medication and notify the HCP

Administer the medication as ordered.

Prepare to administer vitamin K (AquaMephyton).

Assess the client for abnormal bleeding.

Fat embolism

Answer and Explanation

The Correct Answer is B

A. Hold the medication and notify the HCP: This is unnecessary. An INR of 2.7 is within the therapeutic range for a client with a mechanical valve replacement (2.5 to 3.5). No intervention is required.

B. Administer the medication as ordered: The INR of 2.7 is within the desired therapeutic range for clients on warfarin with mechanical valve replacements, so the nurse should proceed with the prescribed dose.

C. Prepare to administer vitamin K (AquaMephyton): Vitamin K is used to reverse the effects of warfarin if the INR is too high (usually greater than 5).

D. Assess the client for abnormal bleeding: While important, this is not the first action. The INR is within the therapeutic range, so the priority is to administer the medication.

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Correct Answer is D

Explanation

A. The client's blood pressure has decreased since the last visit. Decreased blood pressure is not a typical early sign of mitral valve stenosis.

B. The client's liver is enlarged and the abdomen is edematous. These are signs of more advanced heart failure, which can result from mitral valve stenosis but are not early indicators.

C. The client has jugular vein distention and 3+ pedal edema. Jugular vein distention and pedal edema are later signs of heart failure caused by mitral valve stenosis, not early signs.

D. The client complains of shortness of breath when walking. Shortness of breath on exertion is an early sign of mitral valve stenosis as the left atrium is unable to effectively pump blood into the left ventricle, leading to pulmonary congestion and difficulty breathing.

A. A patient with second-degree atrioventricular (AV) block, type 1. rate 60, who is dizzy when ambulating B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due.

Correct Answer is D

Explanation

A. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating. While dizziness may be a concern, second-degree AV block type 1 (Wenckebach) typically resolves without immediate intervention.

B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago. This patient is stable, and recovery from cardioversion typically involves monitoring, but the patient does not require immediate intervention.

C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due. The patient is stable, and the dose of warfarin can be administered after assessing the patient’s overall condition, making it a lower priority.

D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due: The patient whose ICD fired twice is at high risk for life-threatening arrhythmias, and this situation requires immediate evaluation and intervention. The nurse should assess the patient first, and the dose of amiodarone may be administered to manage any underlying arrhythmias.

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A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

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